Pediatric Patients as a Source of Bias in Joseph Lister's Study of Antisepsis

Joseph Lister's (1827-1912) use of carbolic acid to prevent wound infection in open fractures of the extremities (1865) provided a basic science rationale for the practice of surgery. His series of 11 patients included 4 children, aged 7 to 13. Children, today known to better survive a given injury when compared with adults, may have biased his results in favor of survival, and led him to conclude that his method of carbolic-soaked dressing changes prevented fatal wound sepsis. His success with antisepsis may have been less a testament to his application of germ theory to surgery than to the physiological resilience of his young patients.

Robert Lawson Tait (1845-1899): The true innovator of aseptic surgery?

Robert Lawson Tait was an original thinker, a surgical innovator, a controversialist and an iconoclast. He made important contributions to surgery, was an eloquent supporter of Darwinian evolution and women in medicine and opposed vivisection. He is probably best remembered for his high-profile opposition to Listerian antisepsis which continued until his death. While Lister went on to receive the country's highest honours and was lauded throughout the world, Tait received much more modest honours and little subsequent recognition by historians. Yet it could be argued that Tait's system rather than Lister's was the basis of modern aseptic surgery. Tait never changed his views on asepsis over his lifetime and relied on surgical cleanliness, which, combined with his extensive clinical experience, enabled him to achieve outcomes as good or better than with antisepsis. By contrast, Listerism evolved over 30 years, claimed to be based on laboratory data and adopted the new discoveries of the germ theory of disease as they emerged. We compare the systems of Tait and Lister, explore the basis of Tait's opposition to Listerian methods and conclude that Tait's thinking underlies modern surgical practice and that he should receive greater acknowledgement for his contribution to the prevention of surgical infections.

Does a Presurgical Antisepsis Protocol Decrease Surgical Site Infections in Young Children?

National standards for surgical site infection (SSI) prevention for children remain elusive. Our institution developed a presurgical antisepsis protocol that included the three components of chlorhexidine gluconate bathing wipes, chlorhexidine gluconate oral rinse, and povidone-iodine nasal swab. This retrospective cohort study examined data from electronic health records to compare SSI rates before and after protocol implementation. We included children aged 2 through 11 years undergoing any surgical procedure with the use of an incision in the OR (N = 1,356). We did not find any difference in the occurrence of SSI before and after the protocol was implemented. Logistic regression showed that an infection present at the time of surgery was the only significant predictor of an SSI. The implementation of a presurgical antisepsis protocol was not associated with SSI rate reduction in this pediatric cohort.

Mathilde Schott, A Woman's Influence in the Revolution of the Scalpel in the 1890s

Surgery relies on the scalpel; the surgeon's first instrument in every case. From early knives crafted in the pre-historic era to today, the scalpel has evolved along with medical and surgical fields but maintained its critical role and symbolism of operative intervention. A significant catalyst for change in surgical instrument development in the late 1800s was the evolution of anesthesia and antisepsis. Surgical instruments were affected by harsh sterilization techniques, creating need for a method to maintain surgical scalpel sharpness. Mathilde Schott, an early female biomedical engineering innovator, filed a patent (US431153) in 1890 for a detachable scalpel blade. Schott identified and responded to the needs of surgeons at the turn of the 20th century and created a detachable blade and stabilizing lever. Schott persevered in a society unaccustomed to women leaders, subsequently improving medicine, surgery, and engineering.

Effect of aqueous olanexidine versus alcohol-based chlorhexidine for surgical skin antisepsis on incidence of surgical site infections in gastrointestinal surgery: multicentre randomised controlled clinical trial (OEDO trial) protocol

INTRODUCTION

Surgical site infections (SSIs) are among the most common nosocomial infections in surgery patients. Two types of preparations, povidone-iodine and chlorhexidine-alcohol, are commonly used in preoperative antiseptic procedures worldwide. However, there are inconsistencies among international guideline recommendations concerning skin antiseptics. This trial aimed to evaluate the superiority of olanexidine, which reduced SSI rates more than povidone-iodine in our previous randomised trial, over chlorhexidine-alcohol in clean-contaminated surgery.

METHODS AND ANALYSIS

This multicentre randomised controlled clinical trial will compare two antiseptics (1.5% olanexidine and 1.0% chlorhexidine-alcohol) to prevent SSI in clean-contaminated gastrointestinal surgeries with surgical wounds. On providing consent, patients aged <18 years will be included. The primary outcome will be the postoperative 30-day overall SSI rate, while the secondary outcomes will be the postoperative 30-day superficial incisional SSI rate, deep incisional SSI rate, organ/space SSI rate, positive bacterial wound culture rate, cultured bacterial strains, rates of intervention-related toxicity and allergic events (eg, erythema, pruritus, dermatitis and other symptoms of allergy around the region disinfected by the antiseptic during surgery), rate of reoperations due to SSI, medical economic effect indicators (based on health insurance claims) and hospital duration. The Mantel-Haenszel method will be used to estimate the adjusted risk ratio and its 95% CI for the primary analysis, which will compare the treatment effects.

ETHICS AND DISSEMINATION

The protocol was approved by the Institutional Review Board of Keio University School of Medicine and subsequently by the board of each participating site. Participant recruitment began in January 2023. The final results will be published in medical journals after international peer review.

TRIAL REGISTRATION NUMBER

UMIN000049712.

Best Practices and a Business Case for Surgical Site Infection Prevention

Surgical site infections (SSIs) can be costly and result in prolonged hospital stays; readmissions; and additional diagnostic tests, therapeutic antibiotic treatments, and surgical procedures. Evidence-based practices for preventing SSIs include environmental cleaning; instrument cleaning, decontamination, and sterilization; preoperative bathing; preoperative Staphylococcus aureus decolonization; intraoperative antimicrobial prophylaxis; hand hygiene; and surgical hand antisepsis. Strong partnerships among infection prevention personnel, perioperative nurses, surgeons, and anesthesia professionals may enhance perioperative infection prevention. Facility and physician-specific SSI rates should be reported to physicians and frontline personnel in a timely, accessible manner. Together with costs associated with SSIs, these data help determine the success of an infection prevention program. Leaders can develop a comprehensive business case proposal for perioperative infection prevention programs. The proposal should describe the need for the program and anticipated return on investment; it also should focus on the goal of decreasing SSIs by establishing metrics for assessing outcomes and addressing barriers.

Saving private W. H.: The surgical experiences of Dugald Blair Brown (1847-1896): Lieutenant-Colonel, FRCS, Edin., AMD

Dugald Blair Brown, a military surgeon and Fellow of the Royal College of Surgeons, Edinburgh, published twelve papers containing 77 case studies of gunshot wounds that he had treated in the Anglo-Zulu War of 1879 and in the First Anglo-Boer War of 1880-1881. Brown devised a "conservative" method of surgery, the early development of which had been influenced by Thomas Longmore (1816-1895), Joseph Lister (1827-1912), F. J. von Esmarch (1823-1912), and Carl von Reyher (1846-1890). During these conflicts, Brown reacted to surgical practices unsuited to the battlefield and not in the interest of the wounded. One such practice was "expectant" surgery, the practitioners of which dangerously substituted natural healing for immediate wound resection. Brown also criticized "operative" surgeons who, when faced with gunshot wounds of the extremities, expeditiously amputated limbs. Viewing each case as diagnostically unique, Brown tried to salvage limbs, to preserve function, and to accelerate recovery. To achieve these objectives, he used debridement, antisepsis, drainage, nutrition, and limited post-operative intervention.

Further observations on hydrogen peroxide antisepsis and COVID-19 cases among healthcare workers and inpatients

Background

The use of prophylactic antisepsis to protect against coronavirus disease 2019 (COVID-19) has been suggested. This study investigated hydrogen peroxide antisepsis (HPA) at two hospitals in Ghana.

Methods

Cases of COVID-19 among healthcare workers (HCWs) using hydrogen peroxide (HP-HCWs) or not using hydrogen peroxide (NHP-HCWs), vaccinated or unvaccinated, were recorded at Shai-Osudoku Hospital (SODH), Dodowa, and Mount Olives Hospital (MOH), Techiman, between May 2020 and December 2021. The effect of HPA in all inpatients at MOH was also observed. Permutation tests were used to determine P values.

Findings

At SODH, there were 62 (13.5%) cases of COVID-19 among 458 NHP-HCWs but no cases among eight HP-HCWs (P=0.622) from May to December 2020. Between January and March 2021, 10 (2.7%) of 372 NHP-HCWs had COVID-19, but there were no cases among 94 HP-HCWs (P=0.206). At MOH, prior to HPA, 17 (20.2%) of 84 HCWs and five (1.4%) of 370 inpatients had COVID-19 in July 2020. From August 2020 to March 2021, two of 54 (3.7%) HCWs who stopped HPA had COVID-19; none of 32 NHP-HCWs contracted COVID-19. At SODH, none of 23 unvaccinated HP-HCWs and 35 (64%) of 55 unvaccinated NHP-HCWs had COVID-19 from April to December 2021 (P<0.0001). None of 34 vaccinated HP-HCWs and 53 (13.6%) of 390 vaccinated NHP-HCWs had COVID-19 (P=0.015). No inpatients on prophylactic HPA (total 7736) contracted COVID-19.

Conclusion

Regular, daily HPA protects HCWs from COVID-19, and curtails nosocomial spread of SARS-CoV-2.

Chlorhexidine and other alternatives for povidone-iodine in ophthalmic surgery: review of comparative studies

Povidone-iodine (PVI) is a universally accepted antiseptic agent used in ophthalmic surgery. Insufficient antisepsis in patients with self-reported allergies to iodine has led to devastating complications. The aim of this study was to review the current evidence for alternatives to PVI in ocular surgery. Aqueous chlorhexidine has been used as a primary antiseptic agent in Sweden for several years and has proven efficiency and safety; in a study of a large series of intravitreal injections in Australia, the endophthalmitis rates were similar to those after the use of PVI. The evidence related to using other disinfectants such as picloxydine, hypochlorous acid solution, and polyhexanide is scarce. Single studies have shown lower patient discomfort after conjunctival lavage with chlorhexidine or hypochlorous acid than with PVI. No evidence was found to suggest changing from PVI to other antiseptic agents. Disinfectant solutions other than PVI or chlorhexidine will require further investigations to show their utility in ocular surgery.

Guidelines in Practice: Preoperative Patient Skin Antisepsis

Surgical site infections (SSIs) frequently involve resident bacteria (eg, Staphylococcus aureus) on the patient's skin. Strategies to help prevent SSIs include removing soil and transient microorganisms from the skin before surgery. Preoperative decolonization, preoperative bathing, and application of an effective skin antiseptic at the surgical site are components of a multimodal approach to reducing microorganisms to subpathogenic levels. As members of an interdisciplinary team, perioperative RNs are essential in the development and implementation of SSI prevention bundles to promote patient safety. This article discusses recommendations from the AORN "Guideline for preoperative patient skin antisepsis" for decolonization protocols, preoperative bathing, and selection of surgical site antiseptics. A scenario describes the process a facility team uses to determine components of an SSI prevention bundle after recognizing an increase in infections from multidrug-resistant organisms.

Perioperative Interventions to Reduce Surgical Site Infections: A Review

Surgical site infections (SSIs) contribute to increased health care costs and morbidity after procedures as well as prolonged length of stay. Perioperative personnel can use a variety of interventions to help reduce SSI incidence; however, all strategies are not effective for all patients (eg, antibiotic prophylaxis). Results of randomized controlled trials show that some SSI reduction strategies are generally effective, including preoperative skin antisepsis with an alcohol-based agent, closing surgical wounds with triclosan-coated suture, and applying a negative pressure wound therapy device to open and closed wounds. Study results do not show that irrigating clean wounds with crystalloid solutions containing antibiotics or routinely using plastic drapes with or without impregnated iodophor or silver nylon-impregnated dressings significantly reduces SSI incidence. Perioperative leaders should support the implementation of strategies to prevent SSIs and work with interdisciplinary team members to develop an SSI prevention bundle that will meet the needs of their patients.

Impact of Oral Care and Antisepsis on the Prevalence of Ventilator-Associated Pneumonia

PURPOSE

This study aimed to evaluate the impact of oral care and use of chlorhexidine gluconate on the prevention of ventilator-associated pneumonia (VAP) in patients admitted to an intensive care unit (ICU).

MATERIALS AND METHODS

An evaluation was performed on 229 patients admitted to ICU in 2012 (before implementation of oral care protocol) and 329 in 2013 (after the protocol). Oral care was based on the removal of secretions from the oral cavity with 0.12% chlorhexidine solution for brushing and sterile gauze for cleaning before a new aspiration. The cases of VAP were evaluated by observing respiratory signs, radiological changes, and culture and laboratory results. The following data were also analysed: gender, length hospital of stay, mechanical ventilation, use of antibiotics and aetiological agent of infection.

RESULTS

There was a tendency towards lower risk of development of VAP after application of oral care protocol (odds ratio = 0.64-95% CI: 0.39-1.04). There was also a reduction in the incidence of early pneumonia (up to 72 h of hospitalisation). With regard to the aetiological agent of infections, although Gram-negative bacteria predominated in the two periods studied, there was a decrease in the cases of Staphylococcus aureus infection.

CONCLUSION

Oral care protocol has statistically significantly reduced the risk of developing early VAP in ICU patients, thus demonstrating the importance of multidisciplinary teamwork for hospitalised patients.

Perioperative Strategies for Surgical Site Infection Prevention

Surgical site infections (SSIs) are some of the most common and costly health care-associated infections. Although the rate of SSIs has declined significantly in the past decade, patient safety remains at risk. Perioperative nurses employ a variety of evidence-based best practices to prevent SSIs and facilitate a safe surgical experience for their patients, including hand hygiene, preoperative patient skin antisepsis, and antimicrobial irrigation. This article explores the causes of SSIs, such as modifiable and nonmodifiable patient factors and preoperative, intraoperative, and postoperative procedural factors, and discusses some of the specific recommended strategies related to the prevention of SSIs that perioperative nurses can initiate in their workplace.

Equine Skin Antisepsis Using an Alcohol-Based Rub

Alcohol-based antisepsis has been extensively studied in human health care, but only little information is available regarding efficacy and tolerance in other species. The purpose of this study was to determine if an alcohol-based antiseptic is effective at reducing bacterial counts on equine skin and the appropriate contact time to do so, without causing any adverse skin reactions. Samples were collected before and after preparation from clipped sites over both jugular veins of horses and were plated on 3M Petrifilm Aerobic Count Plates in duplicate. Trial 1 tested an alcohol-based product (ET-80% ethanol) against a control of sterile saline at a contact time of 180-second. Trial 2 tested two different contact times of ET-90 and 180 seconds. All samples were assessed for colony-forming unit counts using an automated 3M Petrifilm reader. Data were analyzed by Kruskal-Wallis test, and the significance was set at P < .05. The results determined that ET had a mean 2.95 log₁₀ reduction from prepreparation to postpreparation colony-forming unit counts. A significant difference in log reduction between ET and control (P = .0033) was observed. There was no difference in log₁₀ reduction between the two contact times (P = .75). Mild urticaria was the only skin reaction observed and was often present in both ET and control groups. These findings demonstrate that ET is effective at reducing bacterial counts on equine skin at a contact time of 90 seconds without producing significant adverse skin reaction.

Effect of hand lotion on the effectiveness of hygienic hand antisepsis: Implications for practicing hand hygiene

BACKGROUND

Skin protection products should be used after washing hands with soap, during breaks, after work, and during leisure time. Aside from their beneficial effects, skin care products may also interact with alcohol-based hand disinfectants by reducing their efficacy. The aim of this study was to investigate the effect of a hand lotion on the effectiveness of hygienic hand antisepsis using an alcohol-based handrub.

METHODS

The effect of a protective hand lotion against an isopropyl alcohol-based handrub was investigated in 20 healthy volunteers according to the European standard test procedure EN 1500 in the following combinations: handwashing and application of hand lotion, only application of hand lotion, and no washing and no hand lotion (control), each for 5 minutes or 1 hour before hand antisepsis. The difference in microbiologic before-and-after values were expressed as log reduction factor.

RESULTS

The effectiveness of hand antisepsis was not significantly affected in any of the groups using the tested hand lotion.

CONCLUSIONS

Hand antisepsis may be delayed for 5 minutes after hand lotion application. Shorter time intervals might be possible but were not tested.

AspiriN To Inhibit SEPSIS (ANTISEPSIS) randomised controlled trial protocol

INTRODUCTION

Sepsis is a leading global cause of morbidity and mortality, and is more common at the extremes of age. Moreover, the cost of in-hospital care for elderly patients with sepsis is significant. There are indications from experimental and observational studies that aspirin may reduce inflammation associated with infection. This paper describes the rationale and design of the AspiriN To Inhibit SEPSIS (ANTISEPSIS) trial, a substudy of ASPirin in Reducing Events in the Elderly (ASPREE). ANTISEPSIS primarily aims to determine whether low-dose aspirin reduces sepsis-related deaths in older people. Additionally, it will assess whether low-dose aspirin reduces sepsis-related hospitalisations and sepsis-related Intensive Care Unit (ICU) admissions.

METHODS AND ANALYSIS

ASPREE is a double-blinded, randomised, placebo-controlled primary prevention trial that will determine whether daily low-dose aspirin extends disability-free longevity in 19 000 healthy older people recruited in Australia and the USA. The ANTISEPSIS substudy involves additional ASPREE trial data collection to assess the impact of daily low-dose aspirin on sepsis-related events in the 16 703 ASPREE participants aged 70 years and over, recruited in Australia. The intervention is a daily 100 mg dose of enteric-coated aspirin versus matching placebo, with 1:1 randomisation. The primary outcome for the ANTISEPSIS substudy is the incidence of sepsis-related death in eligible patients. The incidence of sepsis-related hospital and ICU admissions are secondary outcomes. ANTISEPSIS is to be conducted between 2012 and 2018.

DISCUSSION

This substudy will determine whether aspirin, an inexpensive and accessible therapy, safely reduces sepsis-related deaths and hospitalisations in older Australians. If shown to be the case, this would have profound effects on the health of older Australians.

TRIAL REGISTRATION NUMBER

Pre-results, ACTRN12613000349741.

The impact of surgical hand antisepsis technique on surgical site infection

BACKGROUND

Limited evidence exists regarding the effect on superficial and deep incisional surgical site infections (SDSSIs) of alcohol-based hand rubs (ABR) versus traditional aqueous surgical scrubs (TSS). User preferences and practice are unknown.

METHODS

A retrospective cohort study examining SDSSIs using VA Surgical Quality Improvement Program cases before ABR implementation (2007-2009, TSS group) and after (2013-2014, ABR group). A descriptive survey.

RESULTS

SDSSI rates were 1.8% and 1.5% for TSS (n=4051) and ABR (n=2293), respectively (p=0.31). The adjusted odds of SDSSI using ABR was not significant (OR 0.82; 95% CI, 0.51-1.32). Greatest SDSSI risk was from preoperative radiotherapy (OR, 2.78; 95% CI, 1.14-6.78), general surgery (OR, 2.39; 95% CI, 1.30-4.39) and preoperative smoking (OR, 1.58; 95% CI, 1.02-2.44). Of 95 surveys included, 52% favored ABR. Although 95% self-reported correct product application, improper duration was revealed in both groups (TSS 18% and ABR 10%).

CONCLUSIONS

Implementation of an ABR for use in surgical hand antisepsis did not alter SDSSI rates. Improving product knowledge and compliance may improve SSI rates.

The effect of axillary hair on surgical antisepsis around the shoulder

BACKGROUND

Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking.

METHODS

We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test.

RESULTS

There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all).

CONCLUSIONS

Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.

Evaluation of Skin Antisepsis Prior to Blood Culture in Neonates

In our Intensive Care Nursery, coagulase-negative staphylococcus is the most frequent blood culture isolate. As skin antisepsis is critical in preventing blood culture contamination, we examined the efficacy of the chlorhexidine tincture (CH) used in our nursery for this purpose. Staphylococcus epidermidis colonized the forearms of 88% of infants tested, in a mean density of 104 organisms/cm2. Following a 60-second application of CH (0.5% in 70% ethanol), bacterial growth from forearm skin remained abundant in 15/38 infants (39.4%). Cleansing with 70% isopropyl alcohol, followed by CH as above, left abundant residual growth in only 1/37 infants (2.7%) (P<0.001). All 136 S. epidermidis tested were susceptible to CH (MIC<5(μg/ml) and 14 of 15 exposed to CH 0.02% were rapidly killed (≥98% fall in viable counts within 90 sec). We conclude that two-phase antisepsis using isopropanol followed by CH is a more effective preparation for blood culture in neonates than is CH alone.

Multidose Medication Vial Sterility: An In-Use Study and a Review of the Literature

Contaminated multiple-dose medication vials (MDV) have been implicated in transmission of bacterial infections. It has been suggested that MDV be discarded after 24 hours or even after a single use. At our hospital, we cultured 1,223 weekly samples from 864 MDV in-use over a three-month period. Medications included xylocaine, insulin, heparin, immunizations, and miscellaneous agents. None of the samples was culture-positive. The duration of use was 9.5d (median), 18d (mean), and 1-402d (range) with 13% of vials in-use for more than 30 days. The mean duration of use was significantly shorter for medicine wards, emergency room, and outpatient clinics than for surgery and obgyn wards (p<0.05). Heparin and insulin MDV were in-use for significantly less time than xylocaine and miscellaneous agents (p<0.05), and insulin MDV were more regularly dated (p=0.001). The percentage of undated MDV declined significantly by month during die study (p=0.003). These results lend support to our current guideline that MDV should be dated upon opening and that, unless visible or suspected contamination occurs, vials are discarded either when empty or at the manufacturer's expiration date.

[Advance in herbal medicine applied to intracanal antisepsis]

Intracanal antisepsis acts as one of the fundamental steps in root canal therapy. Intracanal medication is very common among the multitudinous root canal disinfection methods so far. However, as the most frequently-used intracanal medication, calcium hydroxide exists some problems, such as insufficient antimicrobial power and antibiogram. Thus exploring new root canal disinfectant is necessary. Herbal medicine is gaining favor for its wide varieties, broad efficacy and affordable prices. The current researches revealed that many kinds of herbs or compound herbal preparations possess good ability of antimicrobial and other properties that superior to those of traditional root canal disinfectants. However, herbal medicine itself and the studies have shortcomings. This paper will provide a review of various herbal alternatives that are being studied of late years.

[Advance in herbal medicine applied to intracanal antisepsis]

Intracanal antisepsis acts as one of the fundamental steps in root canal therapy. Intracanal medication is very common among the multitudinous root canal disinfection methods so far. However, as the most frequently-used intracanal medication, calcium hydroxide exists some problems, such as insufficient antimicrobial power and antibiogram. Thus exploring new root canal disinfectant is necessary. Herbal medicine is gaining favor for its wide varieties, broad efficacy and affordable prices. The current researches revealed that many kinds of herbs or compound herbal preparations possess good ability of antimicrobial and other properties that superior to those of traditional root canal disinfectants. However, herbal medicine itself and the studies have shortcomings. This paper will provide a review of various herbal alternatives that are being studied of late years.

Surgeon behavior and knowledge on hand scrub and skin antisepsis in the operating room

BACKGROUND

Surgical site infections adversely affect patients' well-being. In this study, hand-washing details and adherence to surgical site antisepsis applications among surgical staff were observed and recorded. Then, a questionnaire was given to test surgeons' theoretical knowledge on operating room principles.

METHODS

Staffs from 5 surgical units were selected (surgeons and nurses from general surgery, urology, plastic surgery, thoracic surgery, and gynecology and obstetrics) and observed. They were questioned on the choice and properties of antiseptics, proper duration of hand washing and use of brushes, and essentials of patient skin antisepsis.

RESULTS

A total of 107 observations (53 residents, 27 nurses, 6 attending staff, and 21 academic staff) were done. Overall mean (± standard deviation) hand-washing time was 69.1 (49.8) seconds (range: 43.8-98; p: 0.001). Overall, 79 (73.8%) never used a brush, 18 (16.8%) used the brush for the nails only, and 10 (9.4) used the brush for hands and arms as well as the nails. Mean (± standard deviation) time from the application of skin antiseptic to surgical incision time was 6.7 (3.5) minutes (p: 0.088). According to the questionnaire, surgeons believed that proper hand-washing time should be 4.2 ± 2.8 minutes (p = 0.13). Brush usage was questioned and 50 (70.4%) favored brush usage whereas 21 (29.6%) were against it. The question for mechanism of action of povidone iodine is answered as 'bactericidal' by only 69%.

CONCLUSION

The study shows that both adherence to local hand-hygiene protocols and surgical staffs' basic knowledge about surgical antisepsis are low.

Bacterial change in external auditory canal upon antisepsis with povidone-iodine during tympanoplasty

The aim of this single-arm prospective study was to determine the flora of the external auditory canal (EAC) in inactive chronic otitis media and evaluate the alteration of microorganisms of the EAC during tympanoplasty upon povidone-iodine antisepsis. Sixty-three patients with central tympanic membrane perforation were enrolled in the study. Preoperative swab cultures were obtained and the EAC was packed with povidone-iodine absorbed gauze. Type I tympanoplasty via a retroauricular route was performed. Cultures from the EAC were taken at the end of each operation. Isolated organisms were identified based upon microbiological, morphological, and biochemical characteristics. The most commonly isolated organisms from preoperative samples were normal commensal flora, including 73 coagulase-negative staphylococci (CNS) and 18 diphtheroid bacilli (DB). Less commonly cultured pathogenic species included four isolates of Staphylococcus aureus and three isolates of Candida albicans. No bacteria were observed in five patients. Following povidone-iodine antisepsis, 32 of the samples were negative. Eradication was statistically significant for CNS, DB and pathogen microorganism (P < 0.05). Isolated bacteria differed from those in preoperative swab cultures in eight cases. After antisepsis, diverse strains of the CNS were isolated in 13 cases and 10 patients showed no change in microbial flora. Postoperative culture demonstrated that all seven pathogenic isolates were eradicated (100 %); this selective efficacy of povidone-iodine antisepsis against pathogenic isolates was significant when compared with commensal flora (P < 0.05). These results suggest that povidone-iodine antisepsis of the EAC before tympanoplasty is an effective method for the elimination microorganisms, especially pathogenic bacteria.

Physical interactions of fish protamine and antisepsis peptide drugs with bacterial membranes revealed by combination of specular x-ray reflectivity and grazing-incidence x-ray fluorescence

As a defined model of outer membranes of gram negative bacteria, we investigated the interaction of monolayers of lipopolysacchrides from Salmonella enterica rough strains R90 (LPS Ra) with natural and synthetic peptides. The fine structures perpendicular to the membrane plane and the ion distribution near the interface were determined by specular x-ray reflectivity (XRR) and grazing-incidence x-ray fluorescence (GIXF) in the presence and absence of divalent cations. The unique combination of XRR and GIXF allows for the quantitative identification of different modes of interactions in a high spatial resolution, which cannot be assessed by other experimental methods. Natural fish protamine disrupts the stratified membrane structures in the absence of Ca(2+) ions, while staying away from the membrane surface in the presence of Ca(2+) ions. In contrast, synthetic antisepsis peptide Pep 19-2.5 weakly adsorbs to the membrane and stays near the uncharged sugar units even in the absence of Ca(2+). In the presence of Ca(2+), Pep 19-2.5 can reach the negatively charged inner core without destroying the barrier capability against ions.

The effect of scrubbing hands with iodine-containing solutions on urinary iodine concentrations of the operating room staff

BACKGROUND

Excessive iodine exposure is associated with thyroid dysfunction and thyroid autoimmunity. Most surgical hand-scrub solutions contain large amounts of iodine, and transcutaneous and mucosal absorption of iodine from these antiseptic solutions has been demonstrated. In this study we determined the effect of hand scrubbing with iodine-containing surgical hand-scrub solutions on urinary iodine concentrations (UICs) in operating room staff.

METHODS

The study included 117 surgeons and surgical nurses from two different hospitals who often used surgical hand-scrub solutions as the iodine exposure group and 92 age-matched hospital staff from nonsurgical units of the same hospitals as the controls. In the iodine exposure group, 39 subjects (from hospital 1) used iodine-containing hand scrub solutions intermittently, and the remaining 78 in the surgical staff (from hospital 2) used only iodine-containing hand-scrub solutions. Morning spot urine specimens were collected from all participants for the analysis of UIC.

RESULTS

The operating room staff had significantly higher UICs compared to the control group (142 μg/L [12-822 μg/L] vs. 89 μg/L [10-429 μg/L], p<0.001). UICs from 39% of the subjects from hospital 2 were found to reach levels higher than 300 μg/L.

CONCLUSION

Scrubbing with iodine-containing solutions might lead to iodine excess among surgical staff. Further studies investigating the effects of hand scrubbing with iodine-containing products on thyroid function and on thyroid antibodies of the operating room staff are needed to determine the consequences of this high iodine exposure.

The forgotten role of alcohol: a systematic review and meta-analysis of the clinical efficacy and perceived role of chlorhexidine in skin antisepsis

Background

Skin antisepsis is a simple and effective measure to prevent infections. The efficacy of chlorhexidine is actively discussed in the literature on skin antisepsis. However, study outcomes due to chlorhexidine-alcohol combinations are often attributed to chlorhexidine alone. Thus, we sought to review the efficacy of chlorhexidine for skin antisepsis and the extent of a possible misinterpretation of evidence.

Methods

We performed a systematic literature review of clinical trials and systematic reviews investigating chlorhexidine compounds for blood culture collection, vascular catheter insertion and surgical skin preparation. We searched PubMed, CINAHL, the Cochrane Library, the Agency for Healthcare Research and Quality website, several clinical trials registries and a manufacturer website. We extracted data on study design, antiseptic composition, and the following outcomes: blood culture contamination, catheter colonisation, catheter-related bloodstream infection and surgical site infection. We conducted meta-analyses of the clinical efficacy of chlorhexidine compounds and reviewed the appropriateness of the authors′ attribution.

Results

In all three application areas and for all outcomes, we found good evidence favouring chlorhexidine-alcohol over aqueous competitors, but not over competitors combined with alcohols. For blood cultures and surgery, we found no evidence supporting chlorhexidine alone. For catheters, we found evidence in support of chlorhexidine alone for preventing catheter colonisation, but not for preventing bloodstream infection. A range of 29 to 43% of articles attributed outcomes solely to chlorhexidine when the combination with alcohol was in fact used. Articles with ambiguous attribution were common (8–35%). Unsubstantiated recommendations for chlorhexidine alone instead of chlorhexidine-alcohol were identified in several practice recommendations and evidence-based guidelines.

Conclusions

Perceived efficacy of chlorhexidine is often in fact based on evidence for the efficacy of the chlorhexidine-alcohol combination. The role of alcohol has frequently been overlooked in evidence assessments. This has broader implications for knowledge translation as well as potential implications for patient safety.

Aesthetic fingertip reconstruction with partial second toe transfer

BACKGROUND

Fingertip defect significantly affects the appearance of the hand. The aim of this research was to evaluate the clinical effect of aesthetic fingertip reconstruction with partial second toe transfer.

METHODS

Between July 2005 and December 2008, 17 patients underwent aesthetic fingertip reconstruction with partial second toe transfer. The mean size of fingertip defects was 0.7 cm (ranging from 0.5 - 1.1 cm). Anastomosis was performed between one dominant plantar digital artery and one proper digital artery, between two dorsal digital veins of the toe and two dorsal digital veins of the finger, respectively, for the reconstruction of blood supply to the reconstructed finger. Two plantar digital nerves of the toe were then sutured to two proper digital nerves of the finger for the restoration of fingertip sensation.

RESULTS

All reconstructed fingers survived completely. The follow-up period ranged from 6 to 24 months, and the appearance of the reconstructed fingertip was similar to that of the normal fingertip. Two-point discrimination of the reconstructed fingertip was (7.8 ± 1.3) mm. The recovered pinch strength of the reconstructed finger was about (89.0 ± 5.1)% of that of the normal finger. Donor site healed well without complications.

CONCLUSIONS

Partial second toe transfer is an ideal aesthetic reconstruction method for fingertip defects; it can not only achieve a satisfactory appearance of the fingertip, but can also obtain excellent sensory and motor functions.

[Advances in the structure-activity relationship study of natural flavonoids and its derivatives]

Flavonoids are a large class of compounds widely distributed in nature. Many pharmacological activities of flavonoids have been reported such as anti-cancer, antioxidant, anti-inflammatory, hepatoprotective, antithrombotic, vasodilator, antiviral, antibacterial, antiallergic, and so on. In recent years, domestic and foreign research groups choose natural flavonoids and optimize their chemical structures in order to develop a number of new derivatives with stronger pharmacological activities. As part of the mechanisms are not clear, we need to strengthen in-depth research in the SAR (structure-activity relationship) study for targeted and efficient structure optimization. This paper systematically summarize current researches in the SAR studies of flavonoids and their derivatives, which can serve as a reference for synthesizing new flavonoid derivatives.

Prophylactic antibiotics in aesthetic surgery

Improvements in infection prevention practices over the past several decades have enhanced outcomes following aesthetic surgery. However, surgical site infections (SSI) continue to result in increased morbidity, mortality, and cost of care. The true incidence rate of SSI in aesthetic surgery is unknown due to the lack of a national surveillance system, but studies of SSI across surgical specialties have suggested that many of these infections are preventable. Patient-related factors-including obesity, glycemic control, and tobacco use-may contribute to the development of SSI following aesthetic surgery. In terms of SSI prevention, proper handwashing and surgical skin preparation are integral. Furthermore, the administration of prophylactic antibiotics has been shown to reduce SSI following many types of surgical procedures. Unfortunately, there are few large, randomized studies examining the role of prophylactic antibiotics in aesthetic surgery. The authors review the medical literature, discuss the risks of antibiotic overutilization, and detail nonpharmacological methods for reducing the risk of SSI.

[Pandemic influenza: rapid sanitary-hygienic measures for initial containment of diffusion]

Viral respiratory diseases may be characterized by rapid diffusion in population, that often cause epidemic outbreaks or pandemic. Besides, typical high mutations of involved virus (almost always influenza virus) can reduce the validity of the up to date available vaccine. The achievement of new vaccines can require prolonged period. In addition, the availability and efficacy of antiviral drugs against new viruses should be evaluated before their uses. Influenza virus replication occurs in the epithelial cells of the respiratory system, and viruses, present in contaminated secretions, spread mainly by aerosols generated during sneezing, coughing, and speaking. Direct and indirect contacts with contaminated fomites play a role, in transmission of viral infection, even if they are less relevant than aerosol transmission. In the absence of ready for use vaccines and active drugs, some "non-pharmaceutical" strategies can be considered decisive factors to reduce the diffusion of pandemic influenza. Hand washing and disinfection procedures, isolation of ill persons, different indication for use of surgical masks and respiratory masks have to be carefully considered.